Considerations in the Dental Management of Children with HIV Infection
Pediatric HIV infection <ul><li>85-90% of cases are vertically acquired </li></ul><ul><li>Approximately 30% transmission r...
HIV Infection in Children: Its Effects on Oral Health <ul><li>Children with HIV infection have: </li></ul><ul><ul><li>High...
Pathophysiology <ul><li>Most human cells can be infected by HIV, but most commonly the T-helper lymphocytes (CD4 cells) ar...
Oral Manifestations of Pediatric HIV <ul><li>Over 70% of HIV patients have oral lesions </li></ul><ul><li>Lesions commonly...
Fungal Infections <ul><li>Candidiasis </li></ul><ul><ul><li>Pseudomembranous/thrush </li></ul></ul><ul><ul><li>Erythematou...
HIV Associated Periodontal Disease <ul><li>Linear gingival erythema </li></ul><ul><li>Periodontitis modified by  </li></ul...
Viral Infections <ul><li>Herpes simplex </li></ul><ul><li>Herpes zoster </li></ul><ul><li>Cytomegalovirus </li></ul><ul><l...
Patient Management Objectives in the Oral Health Care of Children with HIV Infection <ul><li>Decrease the morbidity and mo...
Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Prevention of Infection </li></ul><ul>...
Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Antibiotic Prophylaxis </li></ul><ul><...
Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Prevention of Hemorrhage </li></ul><ul...
Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Prevention of Hemorrhage </li></ul><ul...
Risk Factors for Dental Caries in Children with HIV Infection <ul><li>High lactobacilli and mutans streptococci burdens </...
Dental Caries Prevention in Children with HIV Infection <ul><li>Frequent diagnostic visits </li></ul><ul><li>Aggressive us...
Dental Caries Management in Children with HIV Infection <ul><li>Aggressive use of preventive and minimally invasive restor...
Miscellaneous Treatment Considerations in the Oral Health Management of Children with HIV Infection <ul><li>Nitrous Oxide ...
Miscellaneous Treatment Considerations in the Oral Health Management of Children with HIV Infection <ul><li>Life Expectanc...
Miscellaneous Treatment Considerations in the Oral Health Management of Children with HIV Infection <ul><li>Orthodontics <...
Oral Hygiene Considerations in the Management of Children with HIV Infection  <ul><li>Hematologic Considerations </li></ul...
Considerations in the Dental Management of Children with HIV Infection: Summary <ul><li>Life expectancies of children with...
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  • Life expectancy of children with HIV infection continues to improve. To improve their overall health and quality of life increased consideration must be given toward promoting oral health. These objectives may be complicated by the need to respect patient confidentiality and the realization that the underlying diagnosis may not have been previously disclosed to the child. Drawing from “anticipatory guidance” strategies, known morbidities associated with HIV infection in children may be addressed to recognize: the unique risks of HIV infection the community based risks of poverty, and the readily available tools to diagnose, prevent and manage disease. The enormity of the prevalence of HIV/AIDS is reflected in the following global epidemiological data: Over 36 million people living with HIV infection worldwide 14,000 new cases reported daily 40% in women of childbearing age largest proportionate increase in AIDS patients has been among women 1,600 infants born daily with HIV 7,000 adolescents and young adults infected daily 4% of HIV persons worldwide are children 100% mortality rate is suspected ( note: for more global epidemiological date see Module 3, Slide 1) The objectives of this module are to provide: a greater understanding of those factors placing children with HIV infection at risk following routine dental care, and strategies to address these issues with an emphasis on the prevention of predictable morbidities.
  • The majority of pediatric HIV cases in the United States are the result of vertical transmission. Vertical transmission has been documented to occur in the following ways: 1.Transplacental – in utero 2.Intrapartum - during delivery 3.Postpartum – through breast-feeding Infants with in utero infection have a rapid onset of clinical disease while infants with intrapartum or postpartum infection have a slower disease onset. Significant strides have been made in decreasing vertical transmission through the use of antiretroviral medications during pregnancy and the first 6 weeks of life. This intervention has not been associated with birth defects or serious side effects. Nor is there documented evidence of orofacial deformities or dental anomalies. Fewer children are being infected. Those who are HIV positive are living longer due to new antiretroviral drug protocols. Many children can expect to live into the teenage years with a reasonable quality of life. In the United States, the following statistics have been reported: 4000 new cases reported to CDC monthly 17% of seropositive women are of childbearing age 6000-7000 infants born yearly to seropositive females 2% of HIV-infected individuals are children and most are minorities
  • Children with HIV infection are reported to be 15 to 25 times more likely to develop orofacial diseases than non-infected children. These manifestations include, among others, candidiasis, herpes simplex virus infection, salivary gland disease. These children are at higher risk for developing bleeding disorders and adverse side effects to medications. HIV infected children are at greater risk for developing dental caries and periodontal disease because of hyposalivation, high sweetener content of medications, frequent ingestion of cariogenic fluids to prevent dehydration and often inadequate oral hygiene supervision because of living with a sick or overwhelmed parent or inexperienced foster family. Oral discomfort and pain, which may be due to dental caries, abscesses and advanced periodontal disease may have an important impact on the nutritional status of HIV infected children. The toll of pediatric HIV infection in the United States is primarily expressed in the African-American and Hispanic communities and the increased rate of dental caries is added to the already high caries burden experienced within these communities. Access to dental care is a challenge for any socio-economically disadvantaged community. It is an especially difficult challenge for children with HIV infection to have access to qualified, educated and compassionate health care providers. The gap between different populations in terms of access and unmet dental needs is important because oral health is increasingly recognized as a factor in overall health and quality of life. For patients with underlying medical or developmental disabilities, such as HIV/AIDS, access to oral health care is critical in maintaining comprehensive health.
  • T-Helper lymphocyte counts (CD4) cells have been shown to be associated with the progression of HIV infection to AIDS. As a guide, the following may be useful for patients 6-12 years of age. 1-5 year old patients would have CD4 counts nearly 2.5x shown in this guide, with corresponding symptoms. However, in young children, the relative percentage of CD4 cells is of greater value than their absolute numbers in reflecting the degree of immune suppression. CD4 Count (6-12 year old) CD4 Count (1-5 year olds) Diseases 400 &gt;1000 Most patients have no signs of immunosuppression associated disease 301 to 400 751 to 1000 Bacterial skin infections - staphyloccocal 201 to 300 501 to 750 Herpes zoster Candidiasis Tinea Pedia Oral Hairy Leukoplakia 101 to 200 251 to 500 Pneumocystis carinii pneumonia Histoplasmosis Herpes simplex Toxoplasmosis Kaposi’s sarcoma 0 to 100 0 to 250 Wasting syndrome Cytomegalovirus Lymphoma
  • Even children who are well managed medically will exhibit oral manifestations of HIV infection.The most common lesion observed is oropharyngeal candidiasis (OPC). Although OPC may be encountered in non-HIV infected infants, its presence in HIV infected children must be addressed. It is a marker for disease progression and often the initial sign of HIV infection. Linear gingival erythema mimics acute marginal gingivitis, eruption gingivitis and mouthbreathing gingivitis in children. It may be a form of erythematous candidiasis. LGE is also observed in children undergoing chemotherapy or bone marrow transplantation. It is important to recognize this form of gingivitis because it is not responsive to normal oral hygiene measures. Ulcerative lesions including recurrent aphthous ulcers and herpes simplex viral infection are painful conditions the can interfere with nutrition and oral hygiene measures. Both these diseases are common in healthy children. These ulcers tend to recur more frequently and are more aggressive as the immune system declines. Both HIV-associated salivary gland disease and cervical lymphadenopathy, result in diffuse swellings of the face and neck. Concurrent xerostomia, and pharyngeal tonsillar enlargement with subsequent mouthbreathing may increase the risk for plaque accumulation, dental caries and OPC. Children with lymphproliferative disease have a better prognosis initially but with increased survival are at risk for lymphoma.
  • Oropharyngeal candidiasis (OPC) is one of the most common oral complications of pediatric HIV infection.. As HIV disease progresses in children, the risk for developing oral complications increases, as well. Whereas OPC may be a sign of moderate symptoms, the presence of other fungal infections, such as Histoplasmosis and Cryptococcus are more indicative of severely symptomatic patients.
  • There is an association between CD4 counts and the severity of periodontal disease in HIV infected children. Gingivitis in HIV-positive children is associated with poor oral hygiene. Increasing plaque and gingival indices, coupled with decreasing CD4 counts are commonly encountered in children with HIV-associated gingival and periodontal diseases. Linear gingival erythema (LGE), a distinct red linear band of erythema extends 2-3 mm. apically from the free gingival margin. There is typically no loss of attachment, nor is there pocket formation. Conventional therapy, including mechanical debridement of plaque and calculus, together with the use of antifungal agents may be helpful in resolving many cases of LGE. The incidence of necrotizing periodontal diseases is lower in HIV infected children than adults in the United States. It is a common manifestation in children in developing countries. These painful lesions seriously interfere with the nutritional status and medication compliance of young children, thus contributing to wasting disease. Local debridement, plaque control and antibiotics are essential for managing these conditions. However, primary teeth that exhibit significant bone loss should be extracted. Although controversial, periodontitis modified by systemic disease, appears to be associated with HIV infection and a compromised immune system. It is thought that the early recognition and treatment of HIV in children, together with the differing epidemiology of conventional periodontal disease between children and adults, is responsible for lower incidence in children. Its presence should be of concern, as it is a reflection of an underlying irregularity in the host response to oral flora. Frequent recare visits every 3 to 4 months, along with the reinforcement of daily oral hygiene measures and the judicious use of chlorhexidine oral rinses are recommended as soon as incipient disease is diagnosed.
  • All of these viral infections are common childhood infections but there presence in immunocompromised individual may result in more severe disease that is challenging to manage or frequently recurs. The occurrence of viral infections in the first year of life of an HIV infected child, particularly multiple episodes or within the first month of life are considered to be reflective of moderately symptomatic disease. It is important to remember that these diseases are contagious to health care providers and, therefore, proper infection control measures should be taken when providing care. Transmission may occur through exposure to bodily fluids, including saliva and direct physical contact to mucocutaneous surfaces. In general, painful and persistent oral ulcerations may be associated with herpes simplex, varicella-zoster and cytomegalovirus infections. Besides neglect of oral hygiene, nutritional intake and medication compliance are compromised. The establishment of a diagnosis with appropriate antiviral and pain control treatment is important to prevent further deterioration of the immune system and wasting disease. Significant cosmetic concerns with socialization problems may result when facial lesions, including the common wart, molluscum contagiosum or enlargement of the major salivary glands occurs.
  • Patients with a compromised immune system may not be able to tolerate a transient bacteremia following invasive dental procedures. In addition to neutropenia or decreased CD4 counts, patients may develop thrombocytopenia through the course of their disease, thereby increasing the risk for both infection and bleeding. Anemia (Hemoglobin &lt; 8g/dl) is often associated with children with symptomatic HIV infection, and results in increased risk of bleeding. The morbidity associated with dental treatment should be addressed through the use of prophylactic antibiotics, granulocyte stimulating growth factors and platelet transfusions, as warranted. Consultation with the child’s primary care provider, as well as other specialists on the care team, should be undertaken prior to initiating a dental treatment protocol. The decision to proceed with treatment must be based upon knowledge of the patient’s hematologic and immunologic status, as well as the urgency of the dental needs. Elective treatment may be deferred until a patient’s immunologic or hematologic status improves or stabilizes.
  • The absolute neutrophil count (ANC) is a reflection of the patient’s ability to respond to an infectious insult, such as from a transient bacteremia. The ANC is calculated on the basis of a complete blood count (CBC) with differential. The percentage of neutrophils or polymorphonuclear leukocytes (PMN) is multiplied by the total number of white blood cells (WBC).
  • There may be varied reasons and indications for the utilization of antibiotic prophylaxis in the management of children with HIV infection. In addition to the use of prophylactic antibiotics when ANC is less than 1000/mm 3 , patients with history of recurrent infections, CD4% &lt; 15, underlying cardiac disease, shunts or in-dwelling catheters should be evaluated. This protocol may be modified depending on the recent antibiotic history of the patient and the type of infection. Although the present protocol is instituted for the prevention of transient bacteremia, additional antibiotics are required frequently to manage a periodontal or odontogenic infection. Depending on the type and extent of the infection and the immune status of the child, the duration of treatment varies but typically ranges from 10 to 14 days.
  • Platelet counts and hemorrhage control are important considerations in the management of children with HIV infection. Based upon the Centers for Disease Control and Prevention’s 1996 Revised Pediatric HIV Classification, a platelet count of less than 100,000/mm 3 that persists for more than 30 days may be reflective of moderately symptomatic disease. Such patients may also have evidence of neutropenia and anemia. Good surgical technique with adequate debridement and primary closure of the lesion site, when possible, is important to decrease the risk of bleeding and infectious complications. Children with HIV infection appear to have delayed eruption of the permanent dentition, as well as an increased risk for ectopic eruption of the anterior teeth. Such ectopic eruption may necessitate the extraction of over-retained primary teeth, following appropriate consideration of the patient’s platelet counts. The dentist should observe the patient following extraction procedures in order to assess the bleeding, even when laboratory measurements, such as platelet count, are within acceptible ranges. Patients that appear to have excessive oozing should be referred to their physician for further evaluation and diagnostic workup. Such attention to the patient’s responses to clinical procedures enhances the role of the dentist in the team approach to comprehensive care.
  • Children with HIV infection often have a higher caries risk because of their socioeconomic status and race. These factors put entire communities at risk for Early Childhood Caries. Children with HIV infection appear to have a caries prevalence that is even greater than observed in their peers. The prevalence of dental caries increases as the CD4 count decreases. Children with HIV infection carry heavier oral burdens of lactobacilli and mutans streptococci. Children with more advanced disease stage have a higher caries prevalence. HIV infected children with higher plaque and gingival indices also have a higher prevalence of dental decay. Regardless of how small the carious lesion is, an aggressive approach to its management must be undertaken. In addition to cariogenic diets, children with HIV infection may also be subject to sucrose containing dietary supplements and medications. Reduced salivary flow may result from the use of these medications. Some children develop HIV encephalopathy with attendant sensory and motor deficits, which may contribute to oral dysfunction and hypomotility. As a consequence, feedings may be lengthy or frequent in number and result in decreased clearance of foods and prolonged contact time between carbohydrates and the teeth.
  • The predictive nature of these elements of risk requires that the oral and dental condition of children with HIV infection be closely monitored and assessed. In an ideal setting, the frequent oral evaluations would begin in the medical home of the child, with primary care physicians and others trained in the recognition of early demineralization and oral health promotion. Since the compliance of HIV infected children with unmet dental needs is poor, it is extraordinarily important to prevent the occurrence of dental decay, and to minimize the need for therapeutic intervention. Module 1 describes in detail strategies for assessing and managing caries risk in a pediatric HIV population. Caries prevention requires both active and passive preventive strategies . (see Module 1, Slide 26) In addition to frequent dental and oral examinations, appropriate fluoride vehicles should be used. For very young children, particularly those at risk for Early Childhood Caries, use of topical fluorides is beneficial. Since children with HIV infection may be using bottled water, consideration should be given to recommending the use of bottled waters with added fluoride. If that is not feasible, fluoride assays of the brand of water used should be undertaken. Any systemic fluoride deficits should be adjusted through age based prescription fluoride supplements. The current regimen for supplemental fluoride is detailed in Module 1, Slide 28. As children get older and are capable of rinsing, without swallowing, over the counter fluoride preparations may be considered. As an alternative for those children who continue to require a systemic supplement and would benefit from rinsing, a swish and swallow preparation may be prescribed. The role of proper oral hygiene cannot be over-emphasized, particularly for patients with high carbohydrate intake and poor oral clearance. This includes brushing of the teeth and tongue at least twice a day and daily flossing as soon as proximal tooth contact is present.
  • Due to the potentially devastating effect of odontogenic infection, particularly in patients with more advanced disease, pulpal management must be undertaken with well established criteria. Although therapeutic vital pulpotomies are highly successful in the primary posterior dentition, they should not be undertaken in the primary anterior teeth. Any clinical or radiographic suggestion that is not consistent with pulpal vitality must be carefully weighed. The presence of spontanous pain, difficulty in controlling pulpal hemorrhage are some of the contraindications to therapeutic vital pulpotomies that are sometimes overlooked, because of the otherwise high success rate. In patients with immunocompromising conditions, strict adherence to guidelines is warranted. In situations where guidelines for pulpotomy procedures are not clearly met, consideration may be given to pulpectomy procedures. Potential contraindications to pulpectomies, such as periapical pathology, should not be overlooked or minimized, as the success rate of a pulpectomy on primary teeth tends to be lower than for pulpotomies. In the event that periapical pathology is present, consideration should be given to microbiologic, culture or histologic evaluation of the lesions. Dental restorations should be durable, but respectful of the patient’s soft tissues. Well contoured restorations will minimize plaque retention and gingival inflammation. Where feasible, extractions should be performed when platelet counts are sufficient. Strategies should be in place to minimize the reliance on platelet transfusions. If extraction must be performed and platelet transfusion is necessary, attempts should be made to address the treatment needs of teeth that have large carious lesions, in order that all necessary extractions be done during the period when sufficient platelets are available to the patient.
  • Although nitrous oxide is considered to be a very benign adjunct in the behavior management of children, its use may be contraindicated in patients with chronic fibrotic pulmonary disease or with significantly diminished pulmonary function. Children with lymphoid interstitial pneumonia (LIP) or who have frequent episodes of pneumonia may not be appropriate candidates for nitrous oxide analgesia. Conscious sedation of patients with HIV infection should be undertaken using clearly established sedation guidelines, such as those continually updated by the American Academy of Pediatric Dentistry. Patients who are asymptomatic or mildly symptomatic may be candidates for conscious sedation. As with all dental treatment protocols, consultation with the child’s primary care provider is mandatory. In the event that the patient is cleared for conscious sedation, particular attention should be paid toward assessing the child’s airway, to ensure that HIV-specific lymphoproliferation, such as enlargement of the tonsils and adenoids, do not reduce the size of the airway. For patients who require general anesthesia in order to deliver necessary dental services, consultation with the child’s primary care provider and anesthesiologist, together with other specialists (as required) is necessary. The child’s care team must perform a risk-benefit analysis in order to determine the safest manner to eradicate an odontogenic infection or obtain a biopsy of a lesion when symptoms are moderate to severe, particularly with cardiomyopathy or pulmonary manifestations. Restorations that have a high likelihood of long term success should be chosen when provision of dental treatment is dependent upon general anesthesia. The patient’s age, ability to maintain oral hygiene, and durability of various restorative materials should all be considered in deciding upon a course of treatment. Minimizing restorative failures and maintaining pulpal integrity are critical elements of successful management of patients with restorative dental needs.
  • Before initiating elective procedures, particularly those that have an extended course of treatment, such as orthodontics, consideration must be given to the medical prognosis of the child and the anticipated life expectancy. The child’s life expectancy should be within the duration of the elective treatment protocol. Additionally, consideration must be given to the psychosocial impact of withholding treatment that other children are likely to receive, particularly those treatments that enhance self image. In children with reasonably good prognoses or anticipated life expectancies, withholding such treatments may send a message of diminished self worth and value. However, the dental provider must also be cognizant of the implications of discontinuing treatment due to a deteriorating health profile. As a child becomes increasingly aware of the disease state, the termination of elective care may send unwanted messages, which may be interpreted by the child as a harbinger of imminent death or debilitation.
  • Prior to the initiation of orthodontic treatment, a careful assessment of the patient’s soft tissues, plaque and gingival indices and history of candidiasis should be made. Before any orthodontic related extractions are undertaken, the child’s hematologic and immunologic states should be known. Although there is no contraindication to the initiation of orthodontic care, the predictable sequelae associated with orthodontic appliances may have some special concerns for patients with HIV infection. Every attempt should be made to minimize soft tissue inflammatory responses secondary to orthodontic appliances. The liberal use of chlorhexidine rinses and acute awareness of oral hygiene are important factors in minimizing gingival inflammation. The use of fluoride rinses, or even high potency fluorides may be of value for children with HIV infection who have orthodontic appliances. Due to the special ability of orthodontic retainers to harbor fungal micro-organisms, attention must be given to the maintenance, care and cleanliness of such appliances or oral prostheses. Endodontic procedures on permanent teeth generally have a high rate of success. Prior to undertaking such treatment, the chronicity of the infection should be assessed. Endodontic procedures that are thought to have a guarded prognosis: combined periodontal-endodontic lesions, large destructive periapical lesions, or involvement of teeth with significant loss of structure. Diseases that may mimic inflammatory lesions associated with pulpal pathosis such as: lymphoma deep mycotic infection, and osteomyelitis.
  • With the exception of linear gingival erythema (LGE), in medically well controlled populations, children with HIV infection do not appear to be at greater risk for the development of periodontal disease in the developed world. However, it appears that decreasing CD4 counts are associated with the severity of periodontal disease, suggesting that immunological dysfunction, rather than local factors may play an important role in disease pathogenesis. This finding is further supported by similar plaque indices in conventional gingivitis (CG) and LGE Although chlorhexidine does not appear to be beneficial in the treatment of LGE, its use in patients with CG, regardless of immune status, is well established. The propensity of adult HIV infected patients to develop periodontal lesions offers a rationale to eliminate any potential local factors that may be present. Chlorhexidine is a useful adjunct for the management of necrotizing periodontal diseases. Children with a thick coating on the tongue and plugged tonsillar crypts who experience frequent episodes of halitosis should brush or scrape the tongue and rinse with chlorhexidine. Other causes of halitosis include dehydration, sinusitis, reflux disease and medications.
  • The dental management of children with HIV infection is ultimately related to 2 factors: Children with HIV infection are at increased risk for developing oral diseases Children with HIV infection are put at medical risk by developing oral diseases Predictable disease patterns must be met with predictably successful prevention or interventions. The special considerations in the management of children with HIV infection are strongly related to their ability to withstand infection and hemorrhage. As such, the variety of dental considerations in the management of such children is relatively small. As with all patients, good and predictable outcomes are the objectives of dental care. However, due to the underlying susceptibility of children with HIV infection to bacterial infection, the dental provider should choose treatment protocols that will provide a wide margin of safety to the patient. Aggressive preventive strategies, coupled with aggressive therapeutic strategies are designed to minimize disease occurrence and treatment failures. Together with the medical team, the dental team can add to the quality of life of children with HIV infection. Early recognition and treatment of soft tissue lesions, decisive treatment of carious teeth can all play a part in maintaining a child’s ability to fully participate in daily events, such as school, play, eating and sleeping.
  • Considerations in the Dental Management of Children with HIV ...

    1. 1. Considerations in the Dental Management of Children with HIV Infection
    2. 2. Pediatric HIV infection <ul><li>85-90% of cases are vertically acquired </li></ul><ul><li>Approximately 30% transmission rate without intervention </li></ul><ul><li><2% to 6% transmission rate with antiretroviral therapy </li></ul><ul><li>Expression of infection may reflect timing in transmission </li></ul><ul><li>Highly variable disease course, but more rapid progression than in adults </li></ul><ul><li>More susceptible to bacterial infections than adults </li></ul><ul><li>20% of HIV infected children are clinically symptomatic within the first year of life </li></ul><ul><li>50% have AIDS by age 5 </li></ul><ul><li>Mean survival is 10 years and increasing with HAART </li></ul>
    3. 3. HIV Infection in Children: Its Effects on Oral Health <ul><li>Children with HIV infection have: </li></ul><ul><ul><li>Higher rates of dental caries </li></ul></ul><ul><ul><li>Higher incidence of periodontal disease </li></ul></ul><ul><ul><li>Higher incidence of soft tissue lesions; including bacterial, viral and fungal infections </li></ul></ul><ul><ul><li>Decreased access to dental care </li></ul></ul><ul><ul><li>Increased risk of enamel hypoplasia </li></ul></ul>
    4. 4. Pathophysiology <ul><li>Most human cells can be infected by HIV, but most commonly the T-helper lymphocytes (CD4 cells) are involved </li></ul><ul><li>Decreased CD4 counts appear to be associated with increasing clinical manifestations and progression of disease </li></ul><ul><li>In young children, the CD4% is a more accurate reflection of immune suppression </li></ul><ul><ul><ul><li>CD4% > 25% No immune suppression </li></ul></ul></ul><ul><ul><ul><li>CD4% 15-24% Moderate immune suppression </li></ul></ul></ul><ul><ul><ul><li>CD4% < 15% Severe immune suppression </li></ul></ul></ul>
    5. 5. Oral Manifestations of Pediatric HIV <ul><li>Over 70% of HIV patients have oral lesions </li></ul><ul><li>Lesions commonly associated with pediatric HIV </li></ul><ul><ul><li>Oropharyngeal Candidiasis (OPC) </li></ul></ul><ul><ul><li>Linear Gingival Erythema (LGE) </li></ul></ul><ul><ul><li>Salivary gland enlargement </li></ul></ul><ul><ul><li>Herpes simplex viral infection </li></ul></ul><ul><ul><li>Recurrent apthous stomatitis </li></ul></ul><ul><ul><li>Cervical lymphadenopathy </li></ul></ul><ul><li>As children with HIV infection have increased survival, they are at risk for additional oral burdens, such as lymphoma </li></ul>Recurrent apthous stomatitis
    6. 6. Fungal Infections <ul><li>Candidiasis </li></ul><ul><ul><li>Pseudomembranous/thrush </li></ul></ul><ul><ul><li>Erythematous </li></ul></ul><ul><ul><li>Hyperplastic </li></ul></ul><ul><ul><li>Angular Cheilitis </li></ul></ul><ul><ul><li>Median Rhomboid Glossitis </li></ul></ul><ul><li>Histoplasmosis </li></ul><ul><li>Cryptococcosis </li></ul><ul><li>Geotrichosis </li></ul>Pseudomembranous Candidiasis
    7. 7. HIV Associated Periodontal Disease <ul><li>Linear gingival erythema </li></ul><ul><li>Periodontitis modified by </li></ul><ul><li>systemic factors </li></ul><ul><li>Necrotizing ulcerative gingivitis </li></ul><ul><li>Necrotizing ulcerative periodontitis </li></ul><ul><li>Necrotizing stomatitis </li></ul>Linear Gingival Erythema Periodontitis modified by systemic factors
    8. 8. Viral Infections <ul><li>Herpes simplex </li></ul><ul><li>Herpes zoster </li></ul><ul><li>Cytomegalovirus </li></ul><ul><li>Human Papillomavirus </li></ul><ul><li>Epstein-Barr virus </li></ul><ul><ul><li>Hairy leukoplakia </li></ul></ul><ul><li>Molluscum contagiosum </li></ul>Herpes simplex Cytomegalovirus
    9. 9. Patient Management Objectives in the Oral Health Care of Children with HIV Infection <ul><li>Decrease the morbidity and mortality due to infection </li></ul><ul><li>Decrease the morbidity due to hemorrhage </li></ul><ul><li>Facilitate the patient’s nutritional status </li></ul><ul><li>Improve the patient’s comfort </li></ul><ul><li>Promote self esteem and socialization through the maintenance or restoration of a healthy smile </li></ul><ul><li>Increase the education of the patient, family and physician relative to the importance of maintaining oral health and the methods to achieve it </li></ul><ul><li>Monitor HIV disease progression through identification of orofacial lesions </li></ul>
    10. 10. Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Prevention of Infection </li></ul><ul><ul><li>Antibiotic Prophylaxis </li></ul></ul><ul><ul><ul><li>Elective Dental Procedures (not presenting as imminent sources of infection) </li></ul></ul></ul><ul><ul><ul><ul><li>If Absolute Neutrophil Count (ANC) is > 1000/mm 3 , prophylactic antibiotics are not necessary </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If ANC is between 500 and 1000/mm3, elective treatment may proceed, following antibiotic prophylaxis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If ANC is < 500/mm 3 or WBC < 2000/mm 3 , elective procedures should be deferred. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If CD4 < 200 prophylactic antibiotics may be considered </li></ul></ul></ul></ul><ul><ul><ul><li>Emergency Dental Procedures </li></ul></ul></ul><ul><ul><ul><ul><li>Any procedure which needs to be performed in order to remove an imminent source of infection may be performed following consultation with physician, and appropriate selection of antibiotics and/or replacement of platelets </li></ul></ul></ul></ul>
    11. 11. Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Antibiotic Prophylaxis </li></ul><ul><ul><li>Children not allergic to penicillin </li></ul></ul><ul><ul><ul><li>Amoxicillin 50 mg/kg (maximum 2 grams) orally 1 hour prior to dental procedure </li></ul></ul></ul><ul><ul><li>Children not allergic to penicillin, but unable to take oral medications </li></ul></ul><ul><ul><ul><li>Ampicillin 50 mg/kg (maximum 2 grams) IV or IM within 30 minutes before dental procedure </li></ul></ul></ul><ul><ul><li>Children allergic to penicillin </li></ul></ul><ul><ul><ul><li>Clindamycin 20 mg/kg (maximum 600 mg) orally 1 hour before dental procedure </li></ul></ul></ul><ul><ul><li>Children allergic to penicillin and unable to take oral medications </li></ul></ul><ul><ul><ul><li>Clindamycin 20 mg/kg (maximum 600 mg) IV or IM </li></ul></ul></ul>
    12. 12. Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Prevention of Hemorrhage </li></ul><ul><ul><li>Elective Dental Procedures </li></ul></ul><ul><ul><ul><li>Platelet count > 50,000/mm 3 </li></ul></ul></ul><ul><ul><ul><ul><li>no special precautions are necessary </li></ul></ul></ul></ul><ul><ul><ul><li>Platelet count < 50,000/mm 3 </li></ul></ul></ul><ul><ul><ul><ul><li>defer treatment, unless imminent or near term odontogenic infection would ensue or if a biopsy is required for diagnosis and treatment of an oral lesion </li></ul></ul></ul></ul><ul><ul><ul><li>Anemia - Hemoglobin < 8 gm/dl </li></ul></ul></ul><ul><ul><ul><ul><li>defer treatment, unless imminent or near term odontogenic infection would ensue </li></ul></ul></ul></ul>Over-retained primary incisors in need of elective extractions
    13. 13. Hematologic Guidelines for Dental Management of Patients with HIV Infection <ul><li>Prevention of Hemorrhage </li></ul><ul><ul><li>Emergency Dental Procedures for the control of pain, infection or biopsy procedure in order to establish a diagnosis </li></ul></ul><ul><ul><ul><li>Platelet count > 50,000/mm 3 </li></ul></ul></ul><ul><ul><ul><ul><li>no special precautions are necessary </li></ul></ul></ul></ul><ul><ul><ul><li>Platelet count < 50,000/mm 3 </li></ul></ul></ul><ul><ul><ul><ul><li>consider platelet replacement </li></ul></ul></ul></ul><ul><ul><ul><li>Anemia - Hemoglobin < 8 gm/dl </li></ul></ul></ul><ul><ul><ul><ul><li>consider transfusion </li></ul></ul></ul></ul>Painful and infected primary incisors
    14. 14. Risk Factors for Dental Caries in Children with HIV Infection <ul><li>High lactobacilli and mutans streptococci burdens </li></ul><ul><li>Increased plaque indices </li></ul><ul><li>High carbohydrate dietary supplements </li></ul><ul><li>Frequent intake of juices, milk and other sweetened beverages to prevent dehydration </li></ul><ul><li>Cariogenic effects of oral medications </li></ul><ul><li>Decreased salivary flow associated with medications </li></ul><ul><li>Oral dysfunction/developmental delay/failure to thrive </li></ul><ul><ul><li>Poor clearance of foods/medications </li></ul></ul>
    15. 15. Dental Caries Prevention in Children with HIV Infection <ul><li>Frequent diagnostic visits </li></ul><ul><li>Aggressive use of fluorides </li></ul><ul><ul><li>Systemic, if necessary (as per CDC guidelines) </li></ul></ul><ul><ul><li>High potency, operator applied </li></ul></ul><ul><ul><li>High potency, daily use </li></ul></ul><ul><ul><li>Low potency rinses </li></ul></ul><ul><ul><li>Fluoride varnishes </li></ul></ul><ul><li>Promote prevention and oral hygiene measures </li></ul><ul><ul><li>Aggressive plaque control measures </li></ul></ul><ul><ul><ul><li>Chlorhexidine rinses </li></ul></ul></ul><ul><ul><ul><li>Education of caretakers </li></ul></ul></ul><ul><li>Pit and Fissure Sealants </li></ul>
    16. 16. Dental Caries Management in Children with HIV Infection <ul><li>Aggressive use of preventive and minimally invasive restorative strategies </li></ul><ul><ul><li>Dictated by the age of the patient, extent of the caries, and previous history of caries </li></ul></ul><ul><ul><ul><li>Preventive resin restorations </li></ul></ul></ul><ul><li>Adherence to pulpal therapy guidelines </li></ul><ul><ul><li>Aggressive treatment of non-vital primary teeth </li></ul></ul><ul><ul><li>Restrictive criteria for assessing pulpal vitality </li></ul></ul><ul><li>Well contoured restorations </li></ul><ul><li>Appropriate use of prophylactic antibiotics </li></ul><ul><li>Platelet supplementation </li></ul>
    17. 17. Miscellaneous Treatment Considerations in the Oral Health Management of Children with HIV Infection <ul><li>Nitrous Oxide </li></ul><ul><ul><li>Evaluate pulmonary function and ability to breathe through the nose </li></ul></ul><ul><li>Conscious Sedation </li></ul><ul><ul><li>Evaluate size of tonsils and pulmonary function </li></ul></ul><ul><ul><li>Potential for drug interaction with HIV medications and midazolam and meperidine </li></ul></ul><ul><li>General Anesthesia </li></ul><ul><ul><li>Consult with pediatrician and anesthesiologist </li></ul></ul>
    18. 18. Miscellaneous Treatment Considerations in the Oral Health Management of Children with HIV Infection <ul><li>Life Expectancy </li></ul><ul><ul><li>Duration of treatment </li></ul></ul><ul><ul><li>Prognosis of treatment </li></ul></ul><ul><li>Psychosocial </li></ul><ul><ul><li>Image enhancement </li></ul></ul><ul><ul><li>Normalcy </li></ul></ul><ul><ul><li>Discontinuation of elective or image enhancing procedures </li></ul></ul>
    19. 19. Miscellaneous Treatment Considerations in the Oral Health Management of Children with HIV Infection <ul><li>Orthodontics </li></ul><ul><ul><li>Chlorhexidine rinses </li></ul></ul><ul><ul><li>Fluoride supplementation </li></ul></ul><ul><ul><li>Fastidious Oral Hygiene </li></ul></ul><ul><ul><li>Meticulous care of retainers and appliances </li></ul></ul><ul><li>Endodontics </li></ul><ul><ul><li>No contraindication with appropriate diagnosis </li></ul></ul>
    20. 20. Oral Hygiene Considerations in the Management of Children with HIV Infection <ul><li>Hematologic Considerations </li></ul><ul><ul><li>Daily tooth brushing, deplaquing of the tongue and flossing when ANC > 500/mm 3 and platelet count > 20,000/mm 3 </li></ul></ul><ul><ul><li>Dental hygiene efforts with moist gauze or toothette only when ANC < 500/mm 3 or platelet count < 20,000/mm 3 </li></ul></ul><ul><li>Chlorhexidine Rinses </li></ul><ul><ul><li>Potential adjunct in the management of Conventional Gingivitis (CG) </li></ul></ul><ul><ul><li>Effective adjunct for necrotizing periodontal diseases </li></ul></ul><ul><ul><li>May be beneficial for decreasing halitosis </li></ul></ul>
    21. 21. Considerations in the Dental Management of Children with HIV Infection: Summary <ul><li>Life expectancies of children with HIV infection are rising </li></ul><ul><li>Children with HIV infection are at greater risk for oral and dental diseases </li></ul><ul><li>Consultation with the medical community is required in order to assess risk/benefit associated with treatment </li></ul><ul><li>Aggressive dental management is indicated in an effort to prevent or manage oral and dental disease </li></ul>

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